PHILIPPINE CHILDREN’S MEDICAL CENTER
Quezon Avenue, Quezon City
CASE MANAGEMENT
APPROACH TO PATIENTS WITH SCROTAL ENLARGEMENT
March 23, 2015
Presentor: Regine P. Dominguez, MD
Reactor: Dexter S. Aison M.D.
Moderator: Eve G. Fernandez M.D.
CASE 1
Residents in charge: Karen Icel Bautista M.D.- insert middle initial
Fellows in charge: Roselda Mirasol M.D.- insert middle initial
Patient is JD, a two year old male from Sampaloc, Manila who was seen for the first
time at our institution last February 25, 2015.
Chief Complaint: Scrotal enlargement, left
Informant: Mother
Reliability: Good reliability
History of Present Illness:
Two years prior to consultation, when the patient was on the 3rd day of life, mother
noted patient’s left scrotum to be larger compared to the right. There was no associated
vomiting, constipation or diarrhea. Consult was done with a private pediatrician. Assessment
was hydrocele and was advised observation.
Since then, the left scrotal mass would increase in size especially when crying and
straining. Size would spontaneously decrease without manipulation. There was no
associated fever, skin changes, abdominal pain or fever noted.
Few hours prior to consultation, scrotal mass was palpated when patient started to
cry. However, there was no spontaneous reduction of the mass size prompting consult at our
institution.
Review of Systems: - kulang
No weight loss.
No rashes.
No cough and colds.
No difficulty of breathing.
No oliguria.
Maternal and Birth History
Patient was born to a thirty two year old G3P3 (3003) mother with no history of
alcohol and tobacco use during pregnancy. Prenatal check-ups were done starting at three
months age of gestation at a local clinic with a midwife. During the sixth month of gestation,
mother had cough and colds for three days, which spontaneously resolved without
medication. At the seventh month of gestation, mother was referred to a secondary hospital
for delivery. During consult, blood pressure was noted to be elevated. Unrecalled
antihypertensive medications were given and mother claimed that blood pressure then was
controlled
Patient was born full term via Caesarian section secondary to a nonreassuring fetal
heart rate pattern. Patient had good cry and activity. No cyanosis, no jaundice and no
difficulty of breathing were noted. There was no cord coil or meconium stained amniotic fluid.
Patient had bowel movement and urine output on the first day of life. Birth weight was 4
kilograms. Patient was discharged on the third hospital day. Newborn screening was done.
No hearing screening was done.
Nutritional History
Patient was breastfed until the age of one year and six months. Complimentary
feeding was started at six months. Currently patient has four to five meals per day consisting
of 1 cup of rice mixed with soup and minced vegetable or meat.
Immunization history
Patient received one dose of BCG, three doses of DPT, three doses of OPV, three
doses of Hepatitis B, one dose of Measles at a local health center with no untoward
reactions. No MMR and no Hib vaccines were given
Growth and Developmental History
Gross motor: Rolled over at the 6 months
Crawled at 10 months
Walked independently at 16 months.
Ran at 2 years old
Fine motor: Feeds self with crackers at 10 months
Language: Mama and papa at 10 months, Walks well at 18 months
Social:
Social smile at 3 months, Laughs out loud at 5 months
Family History
(+) Hypertension – maternal
(-) Diabetes mellitus
(-) Bronchial asthma
(-) Cancer
33 year old
bookeeper
34 year old
housewife
Personal and Social History
Patient lives with five household members in a single level house, well lit and well
ventilated. Water source is mineral water. Garbage collection was done regularly. No
exposure to second hand smoke. No nearby factories noted.
Past Medical History
No previous hospitalization.
No allergies
No history of measles or varicella
Physical Examination
Awake, alert, not in cardiorespiratory distress,
Vital signs BP 90/60, HR 100 bpm, RR 24 cpm Temp
Weight: 13. 6 (z>0 ), Height 93 cm (z >0)
No jaundice, no rashes
Anicteric sclera, pink palpebral conjunctiva,
No tragal tenderness, non-hyperemic external auditory canal, intact tympanic membrane
Moist buccal mucosa, nonhyperemic posterior pharyngeal wall
No cervical lymphadenopathies
Symmetric chest expansion, no retractions, no lagging, clear breath sounds
Adynamic precordium, normal rate, regular rhythm, PMI at 4th left intercostal space,
midclavicular line, no heaves, thrills, lifts and murmurs
Globular abdomen, no visible veins, normoactive bowel sounds, no tenderness, no masses,
no organomegaly
(+) Left scrotal mass extending from inguinal area, nontender, (+) transillumination test
Full pulses, capillary refill time less than 2 seconds, warm extremities
Assessment: Inguinal Hernia, left, reducible
Course at the OPD
Patient was referred to Surgery and assessment was inguinal hernia, left, reducible. Patient
was scheduled for herniorrhaphy and is currently awaiting schedule.
CASE 2:
Fellow in charge: Marjorie Grace P. Apigo M.D.
Urology fellow in charge: Dr Hao/ Dr. Flores – full name MD sa dulo
Patient is DT, a 2 year old male from Quezon City who came in last February 23, 2015 for
the first time at our institution
Chief complaint: scrotal enlargement, right
Informant
Reliability
History of Present Illness:
Six months prior to consultantion, mother noted that the patient’s right scrotum was
larger than the patient’s left scrotum. Both right and left scrotum noted to have gradually
increased in size measuring. There was no associated pain, fever, constipation, vomiting or
increase in size when patient strains or cries. Persistence of the mass lead to consult with a
private surgeon and was advised surgery.
Review of Systems
No weight loss,
No rashes.
No jaundice
No cough.
No difficulty of breathing
Birth and Maternal History
Patient was born to a thirty seven year old G4P3 (4013) with regular prenatal checkup at Mary Chiles Hospital starting at three months age of gestation. Mother denied alcohol
and tobacco use and claims compliance to multivitamins and ferrous sulfate. Patient’s
mother is a known case of hypothyroidism and was on Levothyroxine during pregnancy.
Normal ultrasound, urinalysis and CBC were noted during pregnancy. No history of
hypertension, asthma and diabetes were noted.
Patient was born full term via normal spontaneous delivery at a private hospital
delivered by an obstetrician. Patient had good cry and activity at birth. There was no cord
coil and no meconium stained amniotic fluid. Bowel movement and urine output noted within
the first day of life. Newborn screening done with normal results.
Nutritional History
Patient was never breastfed and was on milk formula since birth (Bonna)
Complimentary feeding started at 6 months with mashed vegetables.
Immunization History:
Patient received one dose of BCG, three doses of DPT, three doses of OPV, three
doses of Hepatitis B and one dose of Measles at a local health center with no untoward
reactions
Growth and Developmental History
Gross motor: Sits with support at 8 months Walked independently at 13 months.
Ran at 2 years old
Fine motor: Currently can hold spoon
Language: Currently can say 20-30 words.
Social: Social smile at 2 months, Laughs out loud at 4 months
Family History
40 year old
businessman
41 year old
employee
(-) Hypertension
(+) Diabetes mellitus
-maternal
(-) Bronchial asthma
(-) Cancer
(+) Thyroid disease
– maternal
Personal and Social history
Patient lives with five household members in a two level house with good ventilation
and lighting. No exposure to second hand smoke. No pets at home. Garbage collection was
done once a week.
Past Medical History
No previous hospitalization
No known allergies to food and medication
No history of varicella or measles
Physical Examination
Awake, alert not in cardio respiratory distress
BP 90/60, CR 110 bpm, RR 19 cpm, Temperature 36.7
Weight 12.6 kg (z<-2 ), Height 87 (z >0)
Pink palpebral conjunctiva, Anicteric sclera
No tragal tenderness, external auditory canal nonhyperemic, tympanic membrane intact
Nasal septum midline, turbinates not congested
Moist buccal mucosa, nonhyperemic posterior pharyngeal wall
No cervical lymphadenopathies
Symmetric chest expansion, no retractions, no lagging, clear breath sounds
Adynamic precordium, apex beat at 5th ICS MCL normal rate and regular rhythm, no murmur
Soft globular abdomen, normoactive bowel sounds, no tenderness, liver and spleen not
enlarged, no palpated masses
(+) transillumination test
No inguinal bulging, bilateral scrotum enlarged 4x4 cm, soft with no tenderness
Assessment: Hydrocoele, right
Course at OPD
Patient was seen at the General OPD and was referred to Urosurgery. CBC, urinalysis were
requested for preoperative clearance. Patient was scheduled for herniotomy.
CASE 3:
Resident in charge: Dr. Raisa Linsy Yu
Fellows in charge: Dr. Hao/ Dr. Flores
Patient is AC 1 year old and 5 month old male from Bulacan who came in for consult
for the first time at our institution
Chief complaint: right scrotal enlargement
Informant
Reliability
History of Present Illness
Three months prior to consult, mother noted patient’s right scrotum to be larger than
patient’s left scrotum. No associated hyperemia. No change in size noted upon crying or
defecation. No urinary and bowel symptoms noted.
Two weeks prior to consultation, mother noted increase in the size of the mass at the
right scrotal sac measuring. No other associated symptoms noted. No fever, pallor and
urinary symptoms noted. Increase in the size of the mass lead to consult at our institution.
Review of Systems
No weight loss,
No rashes.
No cough.
No jaundice
No difficulty of breathing
Birth and Maternal History
Patient was born to an eighteen year old G1P1 (1001), nonsmoker, non-alcoholic
beverage drinker. The mother had regular prenatal check-up starting at three months at a
Local Health Center. She took multivitamins and ferrous sulfate and denies history
hypertension, diabetes and asthma. There was also no history of upper respiratory infection
and urinary tract infection.
Patient was born full term via normal spontaneous delivery at a lying-in clinic
delivered by a midwife. No meconium stained amniotic fluid. No cord coil. Birth weight was 3
kg. Newborn screening was normal.
Nutritional history
Patient was breastfed until three months of life. Milk formula started thereafter.
Complimentary feeding started at six months. Currently, is a picky eater with 4 meals per
day. Meals consisted of ½ cup of rice and 1 piece of hotdog or 2 matchbox sizes of minced
meat or fish.
Immunization history
Patient received one dose of BCG, three doses of DPT, three doses of OPV, three
doses of Hepatitis B and three doses of Hib, 1 dose of Measles and 1 dose of MMR at a
local health center with no untoward reactions.
Family History
22 laborer
19 housewife
(-) Hypertension
(-) Diabetes mellitus
(-) Bronchial asthma
(-) Cancer
Growth and Developmental History
Gross motor – Crawled at 6 months, Stands alone at 10 months, walks alone at 15 months,
runs at 17 months
Fine Motor – holds a bottle at 10 months
Language – Babbles at 8 months, two word phrases at 12 months
Social- social smile at 2 months, Laughs out at 5 months
Personal and Social History
Patient lives with extended family maternal side in a single level house, fairly lit and
ventilated. Water source is store bought mineral water. Garbage collection was done twice a
week. No pets at home. No exposure to second hand smoke.
Past Medical History
No previous hospitalization
No known allergies to food and medication
Physical Examination
Awake, comfortable, not in cardiorespiratory distress
BP: HR 102 bpm, RR 24 cpm Temp 38
Weight: 8.2 kg (z -2 ) ; Height: 74 cm (z < -3 )
Warm skin, no rashes
Anicteric sclera, pink palpebral conjunctiva
No tragal tenderness, external auditory canal, tympanic membrane intact
Nasal septum midline, turbinates not congested
Moist buccal mucosa, nonhyperemic posterior pharyngeal wall
No cervical lymphadenopathies
Symmetric chest expansion, no retractions, no lagging, clear breath sounds
Adynamic precordium, apex beat at 5th ICS MCL, no heaves, lifts, thrills, no murmur
Flat abdomen, normoactive bowel sounds, no mass, no hepatosplenomegaly, soft,
nontender, no guarding
Right scrotum enlarged, 6 x 4 cm, nontender, hard, noncompressible; Left scrotum 2x2 soft,
No inguinal bulging. (+) transillumination test
No inguinal lymph nodes
Assessment: Scrotal mass, probably yolk sac tumor, right
Course at the OPD
Patient was seen at the OPD and was advised scrotal ultrasound which revealed enlarged
right testes measuring 3.9x2.7x3.4 cm suggestive of abscess and necrosis. Once seen at
the surgery OPD, patient was referred to Urology service. At the Urology OPD, the following
tumor markers were requested. Beta HCG: less than 0.100, LDH was normal at 863.0 and
Alpha feto protein was elevated at 15,041. Assessment was a yolk sac tumor, right. Patient
was admitted and scheduled for radical orchiectomy.